Psychotropic Medication Prescribing in Iraq/Afghanistan Veterans and Vietnam Era Veterans With Posttraumatic Stress Disorder.

A new generation of veterans from Iraq/Afghanistan wars is seeking psychotropic pharmacotherapy for posttraumatic stress disorder (PTSD) from the Veterans Health Administration, but little is known about differences in prescribing practices between this group and Vietnam era veterans with the same diagnosis. The Veterans Health Administration administrative data for fiscal year 2012 were used to compare prescribing for 155,631 Iraq/Afghanistan veterans and for 327,634 Vietnam era veterans diagnosed with PTSD. The proportion of veterans who were prescribed psychotropic medications (altogether and within five of seven medication classes) were not substantially different between veteran groups. Iraq/Afghanistan veterans were more frequently prescribed prazosin (p < 0.0001, relative risk = 1.51). However, the number of prescriptions for anxiolytics/sedatives/hypnotics as well as prazosin and opiates filled by this younger group was lower by a small magnitude (Cohen's d < 0.2). Iraq/Afghanistan veterans have good access to psychopharmacological treatment for PTSD but fill somewhat fewer prescriptions than Vietnam era veterans.

Treatment of veterans with PTSD at a VA medical center: primary care versus mental health specialty care.

OBJECTIVE: Recent military conflicts have generated significantly more demand for treatment of posttraumatic stress disorder (PTSD) as well as concerns about the adverse effects of stigma associated with specialty mental health care. This study examined the extent to which veterans diagnosed as having PTSD received treatment exclusively in primary care settings. METHODS: Administrative data from the U.S. Department of Veterans Affairs (VA) Connecticut Healthcare System for fiscal year 2010 were used to compare the proportions and characteristics of veterans with PTSD (N=4,144) who were treated exclusively in a primary care setting or a mental health specialty clinic. RESULTS: Most (87%) veterans were treated in specialty mental health clinics, and 13% were treated exclusively in primary care. In contrast, 24% of veterans with any mental health diagnosis received treatment exclusively in primary care. Comorbid psychiatric diagnoses were much more prevalent among those treated in mental health specialty clinics than in primary care (86% versus 14%), and psychotropic medications were far more likely to be filled in mental health specialty clinics than in primary care (80% versus 36%). The percentage of veterans with service-connected disabilities did not differ between the two treatment settings. CONCLUSIONS: Despite the VA's successful expansion of mental health services in primary care, the vast majority of patients with PTSD received treatment in mental health specialty clinics. Stigma does not seem to keep veterans with PTSD from receiving care in specialty mental health settings in spite of the availability of services in primary care.

Posttraumatic stress disorder symptoms in Bosnian refugees 3 1/2 years after resettlement.

This study describes the evolution of trauma-related symptoms over 3 1/2 years in a group of Bosnian refugees. Twenty-one refugees received standardized psychological assessments shortly after arriving in the United States and then 1 year and 3 1/2 years later. Of these refugees, 76% met diagnostic criteria for posttraumatic stress disorder (PTSD) at baseline, 33% at 1 year, and 24% at 3 1/2 years. PTSD severity scores in women refugees were higher than scores in men at all three evaluation time points. At the 3 1/2-year evaluation, 44% of women and 8% of men met criteria for PTSD and no correlation was found between PTSD symptom severity and either age or level of trauma exposure. A significant inverse correlation was found between Global Assessment of Functioning (GAF) scores and PTSD severity scores. Refugees who reported better mastery of the English language had significantly higher GAF scores. Although PTSD symptom severity decreased over time, most refugees continued to have at least one or more trauma-related symptoms and 24% still met criteria for PTSD after 3 1/2 years in the United States. Women refugees and those who had not mastered the English language appeared to be more vulnerable to persisting psychological effects of trauma.

An increased capacity for adrenal DHEA release is associated with decreased avoidance and negative mood symptoms in women with PTSD.

We recently found increased adrenal cortisol responses to adrenocorticotropic hormone (ACTH)1-24 and increased pituitary ACTH and adrenal cortisol responses to corticotropin-releasing factor in premenopausal women with chronic post-traumatic stress disorder (PTSD) compared to healthy nontraumatized subjects. This pattern of hypothalamic-pituitary-adrenal axis (HPA) hyper-reactivity has been previously seen in healthy individuals treated with the antiglucocorticoid mifepristone. We therefore investigated whether endogenous plasma levels of antiglucocorticoids such as dehydroepiandrosteroine (DHEA) and progesterone were increased in premenopausal women with PTSD at baseline or in response to adrenal activation by ACTH1-24. The study revealed that DHEA responses to 250 microg ACTH1-24 were increased in 13 PTSD subjects compared to 13 healthy nontraumatized subjects, while DHEA levels were generally increased in the PTSD subjects compared to seven healthy traumatized subjects. Cortisol responses to ACTH1-24 were also higher in the women with PTSD, while progesterone levels and responses were not different among the three groups. In addition, among the PTSD subjects, the peak change in DHEA in response to ACTH1-24 was negatively correlated with the total Clinician Administered PTSD Scale score, while the peak DHEA to cortisol ratio was inversely associated with negative mood symptoms measured by the Profile of Mood States scale. This work suggests that an increased capacity for DHEA release in response to extreme adrenal activation may influence the pattern of HPA axis adaptation to extreme stress, as well as mitigate the severity of PTSD and negative mood symptoms in premenopausal women with PTSD.